Subject: Practitioner Restriction, Suspension, or Termination (Page 1 of 6) Objective: I. To ensure that Health Share/Tuality Health Alliance (THA) uses objective evidence and considers patients wellbeing when deciding restrict, suspend, or terminate a THA Provider. II. To ensure that THA has an objective process by which providers have the opportunity to file an appeal or request a hearing when THA acts to remove or limit their THA panel participation. Policy: I. Only licensed practitioners who are professionally competent and continue to meet the credentials, standards, and requirements established by the THA Quality Management Committee (QMC) will be selected and retained to provide healthcare services to THA members. II. III. IV. The QMC is accountable for recommending any disciplinary or termination action against a Full, Associate, Preferred or Extended Contract, or Ancillary Provider when, in the opinion of the Committee, the provider performs below acceptable quality of care standards. The THA Medical Director or designee may counsel, educate, issue warning or censure notice, request corrective action, or institute retrospective or concurrent monitoring to initiate corrective or disciplinary action against a THA Provider. These actions will be documented in the provider s credentialing file and will be presented to the QMC for formal investigation, as appropriate. A formal investigation into the restriction, suspension, or termination of a practitioner may be initiated when reliable information indicates that the practitioner may have exhibited an act, demeanor, or conduct or that is reasonably likely to be: Detrimental to patient health or safety; Unethical; Contrary to applicable THA policies; Below professional standards; Disruptive of THA operations; An improper use of THA resources; A felony conviction; Personal use of illegal drugs and alcohol (while on duty); or Placement on probation or voluntary limitation by any regulatory agency. V. If the QMC makes a final proposed adverse action decision against a
Subject: Practitioner Restriction, Suspension, or Termination (Page 2 of 6) practitioner, the THA Medical Director or designee will give the practitioner written notice of the action within 60 days of the QMC decision. The written notice will include the following: Notification that a final proposed adverse action has been made against the practitioner, and that, if adopted, becomes a final action that will be reported to the NPDB, pursuant to the Federal Health Care Quality Improvement Act; A description of the final proposed adverse action; The reasons for the final proposed adverse action; A statement that the practitioner has a right to appeal or request a hearing on the final proposed adverse action within 30 days of notice receipt; A statement that the appeal and/or hearing request must be made in writing to the THA Medical Director at the specified address, and sent by personal delivery, certified or registered mail, or by a shipping company; and A copy of this policy. VI. Overview of the Fair Hearing Process a. Any one of the following actions, when recommended or taken, or made based upon deficiencies in the quality of care, professional competence, or professional conduct that affects or could adversely affect the health, safety, or welfare of any THA member and/or is likely to be detrimental to the delivery of patient care, constitutes a final proposed adverse action and may be reason for a hearing: Denial of re-credentialing; Termination of a practitioner s ability to provide healthcare services to THA members; Suspension or restriction of a practitioner s privileges for greater than 14 days. o The fair hearing process only applies to suspensions or restrictions that are in effect for a period of more than 14 days. b. The fair hearing process does not apply to the following: Initial practitioner credentialing; Termination of a participating practitioner s agreement with THA pursuant to a without cause or contract non-renewal provision (inclusive of loss of license privileges through OBME); Termination, restriction, or suspension of a practitioner s ability to provide healthcare services to THA members for reasons that are not related to quality of care, professional competence, or professional conduct which affects or could adversely affect the health, safety, or welfare of THA members and/or is likely to be detrimental to the delivery of patient care (e.g. breach of contract); or Suspension or restriction of a practitioner s privileges for a period of less
Subject: Practitioner Restriction, Suspension, or Termination (Page 3 of 6) than 14 days. VII. VIII. IX. The THA Medical Director may act on behalf of the QMC in fulfilling the Committee s duties under the fair hearing process. If the practitioner fails to request an appeal and/or hearing within the timeframe and/or manner described above (section V), the practitioner will be waived of his/her rights to an appeal and/or hearing; the practitioner is deemed to have accepted the final proposed adverse action. Hearing Preparation a. After receipt of the practitioner s hearing request, the THA Administrative Coordinator will schedule the hearing. The Coordinator sends written notice to the provider, outlining the hearing location, date, and time. A period of at least 30 days following THA s receipt of the written request for a hearing will be given before scheduling the hearing. b. Witness lists and document exchange will be determined by mutual agreement between the practitioner and THA. c. A request for a postponement of the hearing and/or an extension beyond the timeframe above is permitted only one time, and only upon mutual agreement between the practitioner and THA. d. The physical presence of the practitioner is required for the hearing. Failure of the practitioner, without good cause, to appear and proceed at the hearing constitutes a waiver of his/her hearing rights and a voluntary acceptance of the proposed adverse action, which becomes effective immediately. e. The Hearing Panel shall be determined by THA and held by one of the following options: Before an arbitrator who is mutually accepted by the practitioner and THA; Before a hearing officer who is appointed by THA, by and through the THA Chief Executive Officer, and who is not in direct economic competition with the involved practitioner; or As promulgated and implemented by the Oregon Medical Board, pursuant to ORS 441.055 (6-11) and OAR 847-10-095. o The majority of the Oregon Medical Board-appointed Hearing Panel will be comprised of members that are peers of the affected practitioner. X. Hearing Process a. At his/her choice and personal expense, the practitioner is entitled to have an attorney or another representative. b. Both the practitioner and his/her attorney/representative have the following rights, within reasonable limitations:
Subject: Practitioner Restriction, Suspension, or Termination (Page 4 of 6) To be provided with all of the information that is available to the Hearing Panel; To have a record made of the proceedings copies of which may be obtained by the practitioner upon payment of any reasonable charges; To call and examine witness, and to cross-examine witnesses; To present and rebut relevant evidence; To introduce relevant exhibits and documents; To submit a written statement at the close of the hearing, provided that the statement is completed in an efficient and expeditious manner of 30 days or less. c. At the conclusion of the presentation of evidence, the hearing is formally closed. d. The Hearing Panel s decision will act as a recommendation that the QMC will consider in making its final decision on the proposed adverse action. Within 30 days after adjournment of the hearing, a written report will be submitted to the QMC with the Panel recommendations; the report will include findings of fact and a conclusion that articulates the connection between the evidence produced at the hearing and the decision reached. e. The practitioner is notified in writing within 30 days of the QMC determination. XI. XII. XIII. All disciplinary or termination actions shall be reported to the THA Board of Directors for approval by a two-third vote. The post-hearing decision of the THA QMC and THA Board is final and binding. There will be no right of another appeal except as allowed under State and Federal laws. If the final action/decision adversely affects the ability of a practitioner to provide healthcare services to THA members for a period of time greater than 30 days and is based on deficiencies in quality of care, competence, or professional conduct, the practitioner will be reported to the NPDB and applicable State licensing board. References: Health Share RAE Participation Agreement NCQA CR 10 Notification to Authorities and Practitioner Appeal Rights THA Policy IX-1: Peer Review THA Policy X-8: Provider Credentialing Appeal Rights & Notifying Authorities THC Medical Staff Bylaws
Subject: Practitioner Restriction, Suspension, or Termination (Page 5 of 6) Formulated: January 2007 Reviewed: July 2010 August 2011 September 2013 April 2015 December 2016 Revised February 2008 September 2009